Compilation of the Social Security Laws

DEFINITIONS

Sec. 2110. [42 U.S.C. 1397jj](a) Child
Health Assistance.—For purposes of this
title, the term “child health assistance” means payment
for part or all of the cost of health benefits coverage for targeted
low-income children that includes any of the following (and includes,
in the case described in section 2105(a)(1)(D)(i), payment for
part or all of the cost of providing any of the following), as specified
under the State plan:

(6) Prescription drugs
and biologicals and the administration of such drugs and biologicals,
only if such drugs and biologicals are not furnished for the purpose
of causing, or assisting in causing, the death, suicide, euthanasia,
or mercy killing of a person.

(9) Prenatal care
and prepregnancy family planning services and supplies.

(10) Inpatient mental
health services, other than services described in paragraph (18) but
including services furnished in a State-operated mental hospital and
including residential or other 24-hour therapeutically planned structured
services.

(11) Outpatient mental
health services, other than services described in paragraph (19) but
including services furnished in a State-operated mental hospital and
including community-based services.

(23) Hospice care
(concurrent, in the case of an individual who is a child, with care
related to the treatment of the child’s condition with respect
to which a diagnosis of terminal illness has been made.

(24) Any other medical,
diagnostic, screening, preventive, restorative, remedial, therapeutic,
or rehabilitative services (whether in a facility, home, school, or
other setting) if recognized by State law and only if the service
is—

(A) prescribed
by or furnished by a physician or other licensed or registered practitioner
within the scope of practice as defined by State law,

(B) performed
under the general supervision or at the direction of a physician,
or

(C) furnished
by a health care facility that is operated by a State or local government
or is licensed under State law and operating within the scope of the
license.

(27) Enabling services
(such as transportation, translation, and outreach services) only
if designed to increase the accessibility of primary and preventive
health care services for eligible low-income individuals.

(28) Any other health
care services or items specified by the Secretary and not excluded
under this section.

(I) whose family
income (as determined under the State child health plan) exceeds the
medicaid applicable income level (as defined in paragraph (4)), but
does not exceed 50 percentage points above the medicaid applicable
income level;

(II) whose
family income (as so determined) does not exceed the medicaid applicable
income level (as defined in paragraph (4) but determined as if “June 1, 1997” were substituted for “March 31, 1997”); or

(III) who
resides in a State that does not have a medicaid applicable income
level (as defined in paragraph (4)); and

(C) who is not
found to be eligible for medical assistance under title XIX or, subject
to paragraph (5), covered under a group health plan or under health
insurance coverage (as such terms are defined in section 2791 of the
Public Health Service Act).

(A) a child who
is an inmate of a public institution or a patient in an institution
for mental diseases; or

(B) a child who
is a member of a family that is eligible for health benefits coverage
under a State health benefits plan on the basis of a family member’s
employment with a public agency in the State.

(3) Special
rule.—A child shall not be considered
to be described in paragraph (1)(C) notwithstanding that the child
is covered under a health insurance coverage program that has been
in operation since before July 1, 1997, and that is offered by a State
which receives no Federal funds for the program’s operation.

(4) Medicaid
applicable income level.—The term “medicaid applicable income level” means, with respect to a
child, the effective income level (expressed as a percent of the poverty
line) that has been specified under the State plan under title XIX
(including under a waiver authorized by the Secretary or under section 1902(r)(2)), as
of March 31, 1997, for the child to be eligible for medical assistance
under section 1902(l)(2) or 1905(n)(2) (as selected
by a State) for the age of such child.

(5) Option
for states with a separate chip program to provide dental-only supplemental
coverage.—

(A) In general.—Subject to subparagraphs
(B) and (C), in the case of any child who is enrolled in a group health
plan or health insurance coverage offered through an employer who
would, but for the application of paragraph (1)(C), satisfy the requirements
for being a targeted low-income child under a State child health plan
that is implemented under this title, a State may waive the application
of such paragraph to the child in order to provide—

(i) dental coverage
consistent with the requirements of subsection (c)(5) of section 2103; or

(ii) cost-sharing
protection for dental coverage consistent with such requirements and
the requirements of subsection (e)(3)(B) of such section.

(B) Limitation.—A State may limit the application
of a waiver of paragraph (1)(C) to children whose family income does
not exceed a level specified by the State, so long as the level so
specified does not exceed the maximum income level otherwise established
for other children under the State child health plan.

(C) Conditions.—A State may not offer dental-only
supplemental coverage under this paragraph unless the State satisfies
the following conditions:

(I) has the
highest income eligibility standard permitted under this title (or
a waiver) as of January 1, 2009;

(II) does
not limit the acceptance of applications for children or impose any
numerical limitation, waiting list, or similar limitation on the eligibility
of such children for child health assistance under such State plan;
and

(III) provides
benefits to all children in the State who apply for and meet eligibility
standards.

(ii) No
more favorable treatment.—The State child
health plan may not provide more favorable dental coverage or cost-sharing
protection for dental coverage to children provided dental-only supplemental
coverage under this paragraph than the dental coverage and cost-sharing
protection for dental coverage provided to targeted low-income children
who are eligible for the full range of child health assistance provided
under the State child health plan.

(6)Exceptions to exclusion
of children of employees of a public in the state.—

(A) In general.—A child shall not be considered to be described in paragraph
(2)(B) if—

(i) the public agency that employs a member
of the child’s family to which such paragraph applies satisfies
subparagraph (B); or

(ii) subparagraph (C) applies to such child.

(B) Maintenance of effort
with respect to agency contribution for family coverage.—For purposes of subparagraph (A)(i), a public agency satisfies
this subparagraph if the amount of annual agency expenditures made
on behalf of employees enrolled in health coverage paid for by the
agency that includes dependent coverage for the most recent State
fiscal year is not less than the amount of such expenditures made
by the agency for the 1997 State fiscal year, increased by the percentage
increase in the medical care expenditure category of the Consumer
Price Index for All-Urban Consumers (all items: U.S. City Average)
for such preceding fiscal year.

(C) Hardship exception.—For purposes of subparagraph (A)(ii), this subparagraph applies
to a child if the State determines, on a case-by-case basis, that
the annual aggregate amount of premiums and cost-sharing imposed for
coverage of the family of the child would exceed 5 percent of such
family’s income for the year involved.

(2) Creditable
health coverage.—The term “creditable
health coverage” has the meaning given the term “creditable
coverage” under section 2701(c) of the Public Health Service
Act (42 U.S.C. 300gg(c)) and includes coverage that meets the requirements
of section 2103 provided to a targeted low-income child under this title or under
a waiver approved under section 2105(c)(2)(B) (relating to a direct
service waiver).

(3) Group
health plan; health insurance coverage; etc.—The terms “group health plan”, “group health
insurance coverage”, and “health insurance coverage” have the meanings given such terms in section 2791 of the Public
Health Service Act.

(4) Low-income.—The term “low-income child” means a child whose
family income is at or below 200 percent of the poverty line for a
family of the size involved.

(5) Poverty
line defined.—The term “poverty
line” has the meaning given such term in section 673(2) of
the Community Services Block Grant Act (42 U.S.C. 9902(2))[21], including any revision required by such section.

(6) Preexisting
condition exclusion.—The term “preexisting condition exclusion” has the meaning given such
term in section 2701(b)(1)(A) of the Public Health Service Act (42
U.S.C. 300gg(b)(1)(A)).

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